Examination, Diagnosis and
Treatment Planning for
Edentulous or Partially
Edentulous Patients
Rola M. Shadid, BDS, MSc
Procedures Carried Before Denture
Treatment
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General information
Chief complaint & patient expectations
Medical history & current medication
Dental history
Visual & manual examination of the mouth and
head and neck
 Radiographic examination
Continue
 Referring for additional tests or medical
consultation
 Referring for second opinion
 Making alginate impressions & preparing
mounted study models
 Discussion of diagnosis, treatment planning
& prognosis with patient
 Finalizing the fees & obtaining a signed
consent
The First Meeting
 Most important
 Prior to meeting, you should review
general information
 Your confidence is as important as the
treatment itself
 You should be a good listener
 Your communication should be in a
simple & truthful manner
Recording General Information
1. Name
2. Race
3. Occupation
4. Address and telephone no.
5. Previous dentist
Age
With advancing age*:
1. Decrease capacity of tissue to tolerate stress
2. Tissue takes longer time to heal
3. Many diseases are prevalent in older age
4. Women at postmenopause may have psychological
disturbances (exacting or hysterical)
5. Men at this age may be concerned with only comfort
& function (indifferent)
Psychological Evaluation (House
Classification of Denture Patients)
Philosophical patient: well motivated, cooperative,
calm & composed even in difficult cases.
Exacting (critical): likes each step in detail, makes
alternative treatment for dentist, makes severe
demands.*
Continue
Indifferent: not very interested in
treatment, blames the dentist for any
mishap, not follow instructions, been
coerced to come by friend, relative….*
Continue
 Hysterical: easily excited, highly
apprehensive, unrealistic expectations*
 Skeptical: bad results from previous
treatment, doubtful, often have severely
resorbed ridges and poor health, might
have psychological disturbances from
recent personal trajedy #
Chief Complaint & Patient
Expectations
 Patient’s own words
 Why he is seeking prosthodontic
treatment
 You should assess if patient expectations
are realistic or not
 If not realistic, you should educate pt
and scale them down
Medical History*
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Diabetes Mellitus
Cardiovascular diseases
Diseases of joints: osteoarthritis
Diseases of skin: pemphigus ?
Neurological disorders (Bells balsy and
Parkinson)
 Sjogren’s syndrome
 Transmissible diseases
Radiation Therapy Vs. Dentures
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Consequences of Radiation therapy
Preprosthetic surgery
Wearing of previous denture *
Denture Fabrication #
Denture Fabrication in Radiation
Therapy Patient
 Avoid impression material that dry tissue
(impression plaster) or heavily flavored materials
(ZOE)
 Consider non-anatomic teeth
 Teeth set in neutral zone
 Slight reduction in vertical dimension
 Soft liners are controversial due to porosity and
possibility of candida
Current Medication
 Insulin *
 Anticoagulants
 Antihypertensive: dryness & postural
hypotension
 Corticosteroids: dryness, confusion & behavioral
changes
 Antiparkinson agents like Norflex and Akineton:
dryness, confusion & behavioral changes
Dental History
 History of tooth loss: cause, time*
 Edentulous period
Beware of Patients Who Have A
“Bag of Dentures” *
Extraoral Examination
 General appearance (healthy, signs of proper
nourishment?)
 Facial symmetry
 Skin: color, deep wrinkles
 Palpation of the head & neck (lymph nodes
& muscles)
Extraoral Examination
 Muscle tonus
 Neuromuscular
coordination*
 TMJ examination
Classification of Frontal Face
Forms (House, Frush & Fisher) *
Classification of Lateral Face
Forms
 Normal
 Retrognathic
 prognathic
Lips
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Length*
Thickness
Mobility
Smile line
Lip (smile) line *
High smile line
Normal smile line
Intraoral Examination
Cheeks, tongue, floor of the
mouth (FOM), maxillary
tuberosity, hard palate, soft
palate, arch relationship,
residual ridge form, saliva,
undercuts
Cheeks
 Draping of the cheeks over the buccal flanges
essential for peripheral seal
 Opening of Stenson’s duct
 Location for many lesions (lichen planus,
submucosal fibrosis, leukoplakai, malignancies as
sqauamous cell carcinoma (SCC))
Leukoplakia
The Tongue
 Favorable tongue is average sized, moves
freely, covered by healthy mucosa
 Normally, it should rest in a relaxed position
on lingual flanges, this will retain denture &
contributes to denture stability by controlling
it during speech, mastication & swallowing.
Tongue Size
 Normal
 Large *
How to Manage Large Tongue?
1.
2.
3.
4.
5.
Lower the occlusal plane
Use narrower teeth
Increase the intermolar distance
Grind off the lingual cusps
Avoid setting a second molar
Tongue Position
 Normal: normal size and
function. Lateral borders rest at
level of mandibular occlusal plane
while dorsum is raised above it.
Apex rests at or slightly below the
incisal edges of mandibular
anteriors
Tongue Position
 Retruded tongue position
deprives pt of border seal of
lingual flange in sublingual
crescent and also may produce
dislodging forces on distal regions
of lingual flange
Tongue Mucosa
The specialized mucosa covering
the tongue is said to be a
“window” on systemic diseases. *
Frenal Attachments
 Fold of mucosa found
at different locations in
the sulcus region of
upper & lower ridge
 Classification
Class I: sulcal or low
attachment
Class II: midway betw.
sulcus & crest of ridge
Class III: crestal
attachment
(frenectomy)
Floor of the Mouth
 If FOM is near the level of the ridge crest,
retention & stability of denture is less.
 Hyperactive FOM reduces retention & stability
 If great ridge resorption, FOM in sublingual
and mylohyoid regions spills on the ridge
 Patency of submandibular ducts *
Maxillary Tuberosity*
If enlarged:
 the posterior
occlusal plane may
be placed too low
 no enough space to
set all molars
Maxillary Tuberosity
Palpate for undercuts if extreme, denture
might not seat
The Hard Palate
 Class I: U shaped, most favorable for
retention & stability
 Class II : V shaped: Not very favorable*
 Class III: Flat or shallow vault: Not very
favorable, accompanied by resorbed
ridges, poor resistance to lateral forces
V-shaped hard palate
Tori *
 Palatal torus
 Mandibular tori
Bony Prominences
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Midpalatal raphe
Sharp ridge crest
Sharp mylohyoid ridge
Prominent genial tubercles
Bony fragments & fractured root pieces
Tori
The Soft Palate (Palatal Throat Form)
House’s classification *
 Class I: the soft palate is
almost horizontal curving
gently downwards
 Class II: the soft palate
turns downward at about
45 angle from the hard
palte
 Class III: the palate turns
downward sharply at about
70 angle to the hard palate.
Palatal Throat Form
Maxilla
I
II
III
Undercuts
 The contour of a cross
section of a residual
ridge that would
prevent the placement
of a denture or other
prosthesis
Undercuts
Unilateral or bilateral; labial or lingual;
mild, moderate or severe
Common locations:
a)
b)
c)
d)
Labial portion of maxillary anterior ridge
Buccal to maxillary tuberosity
Retromylohyoid area of residual ridge
Labial or lingual slopes of mandibular anterior ridge
Undercuts Management
1. Isolated anterior undercut- not
present any problem
2. Unilateral posterior undercut- may
not present much of a problem as path
of insertion is varied
3. Bilateral undercut-surgical removal
of the more severe one is indicated
Residual Alveolar Ridge
Arch form (House’s classification)
Class I: square
Class II: tapered (V-shaped),
associated with high arched
palate, less retention &
stability
Class III: ovoid (less common)
Residual Alveolar Ridge (Cross Sectional
Contour) *
a.
b.
c.
d.
e.
f.
U shaped
V shaped
Knife edged
Flat
Inverted
Undercut
Soft Tissue Support of the Ridge
 Firm & resilient
 Flappy and hypermobile: poor support
because denture base shifts during
masticatory function
 Management of flappy ridge ranges
from modified impression techniques to
surgery
Anterior Arch Relationships *
Intraoral Examination
 Posterior arch
relationships
 Interridge space
 Residual ridge size
Saliva *
Consistency:
Thin serous: provides an insufficient film for denture
retention.
Thick mucus: thick ropy saliva tends to displace denture.
Mixed
Amount:
Normal: ideal for denture retention
Excessive: make denture const. messy
Reduced: reduced retention and increased soreness;
salivary substitutes may be prescribed
Drugs Causing Xerostomia *
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Diuretics
Antihistamines
Atropine
Anticholinergic
Antihypertensive
Antiparkinson (Norflex)
Corticosteroids
Examination of an Old Denture Wearer
o Esthetics, lip fullness, symmetry, amount
of display during smiling, phonetics, teeth
position, size, excessive wear
o Fracture, cracks, porosity, denture
hygiene
o Occlusal vertical dimension (due to
excessive occlusal wear, OVD may have
reduced)
Reduced vertical dimension
Examination of an Old Denture Wearer
Epulis fissuratum
Angular cheilitis
Papillary hyperplasia
Flappy hyperplastic ridge*
Combination syndrome
Epulis Fissuratum
Inflammatory Papillary
Hyperplasia
Angular Cheilitis (Perleche)
Combination (Kelly’s) Syndrome *
Radiographic Examination
 A routine radiographic exam.
must be ordered to rule out any
bony conditions that could affect
the treatment
 Panomaric radiograph is usually
ordered for denture cases
Radiographic Examination
Fractured roots or roots lying close to the surface
should be removed if pt is fit for surgery; deep
seated retained teeth or root fragments may be
left if they are asymptomatic
Supplemental radiographs may be prescribed if
required such as periapical, occlusal, and lateral
cephalometric
Panoramic Radiograph
Additional Tests & Medical
Consultation
 Routine blood test, blood & urine sugar levels
 Medical consultation
 Dental consultation
Diagnosis
 A specific evaluation of existing
conditions
 Involves thorough examination of all
factors which are bound to affect the
success of treatment
 This includes both systemic & local
factors & the mental condition of the
patient
Treatment Plan
 The sequence of procedures
planned for the treatment of a
patient following diagnosis
 Explained to the patient in a
simple and straightforward
manner including all of the
factors that might complicate
the treatment
Alternate Treatment Plan
 May be less than ideal but is often
necessary for various reasons
Refusal of Treatment
 The patient’s demand may be
unreasonable or against
professional judgment or ethics;
so may refuse treatment or refer
him (“bag of dentures”)
Prognosis
 A forecast to the probable result
of a disease or a course of
therapy
 After considering all the factors,
you should be able to predict the
degree of success that can be
expected & the patient should
know of what can and cannot be
achieved.
Fees & Signed Consent
 When patient agreed on
treatment including fees , he must
sign a written consent to prevent
later misunderstanding
Prescription, Nutritional Supplements,
& Tissue Conditioning
 Assess if nutritional deficiency
 Recommend finger massage of oral tissues
 If old denture wearer, tissue conditioner placed
to condition abused soft tissue
 Instruct patient to discontinue wearing denture
48 hrs prior making final impression
A good clinician is one who is able to diagnose
potential problems during the initial
examination & suggest the best possible
treatment plan compatible with the age,
physical, mental & financial status of the
patient
References
I. Complete Denture Prosthodontics, 1st
Edition, 2006 by John Joy Manappallil,
Chapter 2.
II. Zarb. Prosthodontic Treatment for
Edentulous Patients, 12th edition. Chapter
7.